Stenosis of the larynx and trachea: diagnostics and treatment

36 cases (26 males and 10 females aged 19-69, average age 40.3) of larynx and trachea stenosis (23/36 i.e. 64%) and occlusion (13/36 i.e. 36%) were observed between 1990-1999. The cause of larynx and trachea lesion was the prolonged intubation in 17 (47%) cases, tracheostomy--in 13 (36%) (in 12 cases performed outside our centre), external trauma in 5 cases (14%) and burns of the upper airway in 1 patient (3%). For the diagnosis endoscopic, radiologic and spirometric examinations were performed. Length of the constricted or occluded section was estimated at 5-65 mm. Patients were treated applying three methods: endoscopy, splitting of the larynx and/or trachea and "end to end" anastomosis. In most cases surgical proceeding was multistaged. The best result was obtain after "end to end" anastomosis (all patients were deccanulated).

[Own experience in supracricoid laryngectomy with GHP and GHEP type of reconstruction due to larynx cancer]

The results of the surgical treatment of the larynx cancer (glottic-supraglottic) by supracricoid laryngectomy with CHP and CHEP type of reconstruction were presented. Material consists of 160 cases (88 after CHP and 72 after CHEP). 5 years survival rate was obtained in over 71% of cases in all material. Decannulation was possible in 126 (79%) patients. Feeding tube removal before 4 weeks after operation was done in 139 (87%) cases. In subjective assessment all patients had social efficient speech. Favourable results of the treatment encourage wider application of supracricoid laryngectomy.

[The problem of cervical metastases in vocal cord carcinoma]

On the base of 755 cases of glottic cancer, the occurrence and prognostic importance of lymph node metastases were analysed. Metastases of the vocal cord cancer to cervical lymph nodes are rare. In our material amounted 9.13%. Number of metastatic lymph nodes and N factor influenced the lymph node recurrency. It is not, however, dependence statistically. Surgical treatment of the glottic cancer with various degree of advancement secures good oncological results. In our material 3 and 5 years survival rate accounted to 71.33% and 59.31%. The clinical advancement of the glottic neoplasm does not influence in statistically essential way the increase of metastases to regional lymph nodes.

[Laryngotracheal separation procedure after oncological pharyngeal and laryngeal operations]

Principles of the operative technique and indication for permanent laryngotracheal separation in chronic aspiration after oncological operations are being presented. The operation is done while the tracheostomy is present. It consists of horizontal section of the trachea on the level of the tracheostomy and formation the new one by using the lower of the trachea with the skin. Upper sublaryngeal section of the trachea is being closed by stitches. This operation was performed in our clinic in one patient after partial laryngectomy due to the cancer and in two patients after extended resection of the palatal tonsil, base of the tongue and lateral wall of the hypopharynx. In all the cases the follow up was without major complications.

[Investigative findings on the reconstruction with tissue materials after partial laryngectomy]

Between 1987 and 1999--1289 patients were treated by surgery in the Department of Otolaryngology and Laryngologic Oncology PAM in Szczecin due to the cancer of the larynx. In this group total, eventual subtotal excision of the larynx was carried out in 801 cases. In 154 cases the phonation way was restored. In this study the remaining group of 502 patients was analysed, which underwent partial aiming at restoration of all basic functions of the larynx. In the mentioned group partial vertical laryngectomy was done in 176 cases, and partial horizontal laryngectomy in 326 cases. Larynx reconstruction with the use of tissue materials was carried out in 59 cases after vertical and in 88 cases after horizontal laryngectomy. Shortcomings and advantages of the method of various tissue application were discussed (cartilage of epiglottis, vasculary based pedicle flap of thyroid gland, submaxillary salivary gland, strap muscles among others were used).

[Fronto-lateral laryngectomy with subsequent epiglottoplasty: operative technique]

Operative technique is being presented comprising excision of the larynx neoplasm with the vocal cord and anterior commissure. This kind of operation enables the extension of resection to include the arytenoid cartilage, false cord with laryngeal ventricle, part of the subglottis and the base of the epiglottis. The defect resulted is covered by moved down epiglottis. The operation was done in 98 patients with satisfactory oncological and functional results.

[Results of surgical treatment in advanced (T3, T4) cancer of the larynx]

In ENT Clinic of Medical Academy in Szczecin 962 patients with advanced cancer of the larynx was surgically treated between 1976 to 1995 year. In this group local statement of T3 was observed in 510 cases (53%) and T4 in 452(47%). In the analysis group total laryngectomy was performed in 506 (62.3%) cases, subtotal laryngectomy with phonatory way reconstruction was performed in 234 (24.4%) cases, partial laryngectomy with airway reconstruction in 223 cases (in this number horizontal partial laryngectomy in 207 cases and vertical partial laryngectomy in 15 cases. Efficacy of surgical treatment in 5-years of survival was estimate. In whole material it was 505/962 (52.4%) of cases. Cause of failure, possibility and efficacy its treatment is described.

[Results of the surgery in verrucous carcinoma of the larynx]

Group of 10 patients treated between 1989-1998 at the ENT Clinic of PAM due to verrucous carcinoma of the larynx was presented. All were male aged 45-73 years. Clinical progress of the neoplasm was evaluated as follows: T1NoMo--7 cases, T2NoMo--1 case, T3N1Mo--1 case and T4N2Mx--1 case. In 5 cases the neoplasm was removed in endoscopy. In 2 cases chordectomy was carried out, in 1 extended fronto-lateral laryngectomy with subsequent epiglotoplasty, 1 subtotal laryngectomy with vocal fistula and 1 total laryngectomy. Follow up period amounted 2-10 years. Satisfactory oncological and functional results were obtained. 7/10 patients are alive, among them 2 over 5 years and 3--above 3 years. In 1 case death occurred in the perioperative period. Two patients died 2 and 3 years respectively after operation due to malignancy of different organs without recurrency symptoms in the larynx.

[Hypopharynx carcinoma: treatment results]

Eighty-nine patients with hypopharynx carcinoma treated from 1970 to 1997 at the ENT Clinic of Pomeranian Medical Academy were studied retrospectively. There were only IV a stage patients. The treatment consisted of surgery alone (n = 21), radiotherapy and post-radiotherapy surgery (n = 7), a planned combination of surgery and post-operative radiotherapy (n = 61). The 3-year survival was 34.88%, whereas the 5-year disease-free survival was 25.04%. Radiotherapy applied to operative treatment failed to exert any meaningful positive influence on the overall percentage of survivals. 17 patients had local recurrences and 6 node recurrences. Mainly following factors exerted the influence on appearance of nodal recurrence: component N and the number of metastatic nodes. It was pointed out that the results of treatment of hypopharynx carcinoma are still poor and unchanged despite of developing our skills and using new technology of treatment.

[Rare palate tumors: treatment and results]

8 patients (7 male and 1 female) treated between 1991-1998 in Szczecin centre due to the tumours different than carcinoma planoepithelial of the palate were presented. Their age ranged from 30 to 81 years. The dimension of the tumour ranged from 1 to 5 cm. The diagnosis of those tumours was: adenoid cystic carcinoma--2 cases, rare (unnamed) tumour of low malignancy probably of salivary gland origin--1 case, cystis lined with cylindrical epithelium--1 case. 7/8 patients were treated by surgery and in 3 cases RTG therapy followed surgery. One patient refused the treatment. 6/8 patients are alive. One patient died 2 years after surgery. There is no information about the one, who wasn't operated on. 3 patients remain without complains. 3 developed rhinolalia aperta and one from them (following RTG therapy) complain of dryness in the oral cavity. None from the operated on reports any swallowing problems.

[25 years experience in treatment of glottic cancer with classical extented fronto-lateral laryngectomy]

190 patients with glottic cancer (177 male and 13 female) treated by surgery in the course of the last 25 years are being presented. In 92 cases classic and in 98 extended fronto-lateral laryngectomy was carried out. Diagnostic and surgical procedures, depending on anatomical structures of the larynx infiltrated by the neoplasm, were discussed. Own experiences in reconstruction of tissue's defects with pedicle skin flaps from the nearest neighbourhood (13 cases), vascular pedicle gland flaps (19 cases) and with epiglottis (50 cases) were talked over. 5 years survival rate amounted to 90-91%. Oncological and functional results were presented. The weight of personal experience in the improvement of those results in the last 5 years was stressed.

[Horizontal-glottic laryngectomy: operative technique]

Operative technique is being presented, applied in some cases of glottic cancer with preserved movability of the vocal cords (cancer of both vocal cords, diffuse dysplasia of the vocal cords with cancer in situ, verrucous carcinoma of the glottis, carcinoma of single vocal cord crossing superficially through the anterior commissure into the opposite side). The operation consists of excision of the vocal cords together with part of the thyroid cartilage preserving one or both arytenoid cartilages. Reconstruction is done by join.

[Supra-cricoid laryngectomy with subsequent cricohyoid-epiglottopexy: operative technique]

Operative technique is being presented, applied in the therapy of larynx neoplasms, originating mainly from the glottic-subglottic area. Operative technique consists of exposure of the larynx by "U" skin incision, supracricoid excision of the organ together with the neoplasm and following reconstruction through the anastomosis of the cricoid cartilage with the epiglottis and hyoid bone.

[The problem of hidden metastases in larynx and hypopharynx carcinoma]

On the base of 1901 cases of larynx and hypopharynx carcinoma treated in ENT Department in Szczecin occurrence of occult nodal metastases was analysed. The frequency of such cases was 21%. Clinical statement and localisation of the tumour was the major factors predicted to occurrence of occult metastases. It was statistically pointed out that nodal recurrences occurred mainly among the patients with occult metastases. Survival rate was significantly better in group with no occult metastases (64.9%--3 year and 50.4--5 year) than in group with occult metastases (37.5%--3 year and 27.9%--5 year).

[Treatment of chronic aspiration by Lindeman's tracheosophageal diversion procedure]

Three cases of swallowing disorders have been presented in the course of atrophic lateral sclerosis in two patients, and in the pseudobulbar in one. All patients have been operated on after Lindeman method. It consists in formation of the tracheoesophageal anastomosis--tracheoesophageal diversion. Aim was achieved in all the cases. All patients have been taking food by mouth and recurrences of pneumonia were not observed.

[Diverticulectomy for hypopharyngeal diverticula]

In the Otolaryngology Department of Pomeranian Medical Academy in Szczecin since 1980-1999 14 patients with pharyngo-oesophageal diverticulum were diagnosed and treated. Diverticulectomy was performed in 13 cases. Not dangerous complications during the postoperative period were observed in four cases. In one case it was abscess in postoperative wound, in two cases fistula to soft tissue in prevertebral region and in one case paresis of vocal cord. In all these cases complications retreated spontaneous. We had not observed any recurrence of pharyngo-oesophageal diverticulum. In 6 cases control radiological examination was performed (from 2 months to 7 years after surgical treatment). In all cases we hadn't observed any recurrence of diverticulum. In one case radiological examination revealed diverticulosis in all digestive system. But even in this case we hadn't found recurrence of Zenker's diverticulum. In this paper we discuss other methods of treatment of pharyngoesophageal diverticulum.

[The results of treatment of hypopharyngeal carcinoma: some prognostic factors]

Eighty nine patients with hypopharynx carcinoma treated from 1970 to 1997 at the ENT Clinic of Pomeranian Medical Academy were studied retrospectively. There were only IV stage patients. The treatment consisted of surgery alone (n = 21), radiotherapy and post-radiotherapy surgery (n = 7), a planned combination of surgery and post-operative radiotherapy (n = 61). The 3-year survival was 34.88%, whereas the 5-year disease-free survival was 25.04%. The 5-year survival was related to the preoperative nodal staging (N0--52.8%; N1--17.8%; N2--28.3% and N3--0%), the number of lymph nodes metastases (no metastases 45.1%, 1--28.2%, 2-4--23.9%, > 4--0%), and the size of nodes (0 cm--31.6%, 1-3 cm--21.9%, > 3 cm--30.7%). Radiotherapy applied to operative treatment failed to exert any meaningful positive influence on the overall percentage of survivals. 17 patients had local recurrences and 6 node recurrences. Mainly following factors exerted the influence on appearance of nodal recurrence: component N and the number of metastatic nodes. It was pointed out that the result of treatment of hypopharynx carcinoma are still poor and unchanged despite of developing our skills and using new technology of treatment.

[Results of nasopharynx cancer treatment: some prognostic factors]

42 cases of nasopharynx cancer treated between 1985 and 1995 in ENT and Radiotherapeutic Clinic of the Pomeranian Medical Academy were analyzed. In 15 patients (34.5%) planoepithelial carcinoma was found, in 9 (20.9%)--anaplastic carcinoma, in 6 (13.9%)--lymphoepithelial, and in individual cases--spindle-shaped and mucoepidermal carcinoma solidum. 34 patients were treated by radical irradiation (60-70 Gy doses) and 8--by palliative (20-35 Gy). In 7 patients neck dissection was carried out. Better results were achieved in older patients (over 60 years old) than in younger ones. Prognosis in women was better than in men. 5 years' survival rate for T1-2 group was achieved in 77% of cases. For T3-4 group it amounted to 48%; in N0-1--69% and in N2-3 group--52%. 71% patients with planoepithelial carcinoma, whereas only 48% with undifferentiated carcinoma survived 5 years. The rate of 56% of 5 years' survival time is comparable with good results of other authors.

[The results of radiation and surgical treatment of early vocal cord carcinoma (T1a, T1b)]

Results of surgery treatment from the external access and radiotherapy in early, stage of vocal cords carcinoma were presented. Clinical material consisted of 94 cases with squamous cell carcinoma of vocal cords with stage T1a and T1b treated in Szczecin University Department of Otorhinolaryngology from 1987 to 1996. 51 cases were operated on (26 by chordectomy and 25 by frontolateral laryngectomy). Radiotherapy was applied in 43 patients. The 3 and 5 years' survival rate in the surgery group was 97% and after radiotherapy 88 to 80%. The functional results were also presented. It was concluded that the mode of treatment in early stages of vocal cord carcinoma should be individualized.

[Fibrosarcoma of the larynx]

Fibrosarcoma is the most common neoplasm of the larynx of mesenchymal origin. Between 1991 and 1996 three cases of fibrosarcoma were observed in the ENT Clinic of the Pomeranian Medical Academy. There were two males and one female aged 49-66. It makes 0.5% (3 in 655 cases) of all malignant neoplasms of the larynx treated by surgery in the mentioned period of time. The primary focus of the neoplasm in one case was located in anterior commissure and in the two others--in the vocal cord. In all the cases surgery was done. Results of the treatment were given.

[Surgical treatment of hypopharyngeal cancer: reconstructive methods]

The paper presents a 26-year experience of the ENT Clinic of the Pomeranian Medical Academy in Szczecin with 20 patients who underwent reconstruction of the hypopharynx after resection for locally advanced carcinoma. The procedures were carried out in years 1970-1995. The reconstructions included 7 musculomucosal pedicle flaps obtained from the base of the tongue, 5 epiglottis pedicle flaps, 4 tubed pectoralis major musculocutaneous flaps, 1 vascular pedicle submandibular gland flap, 1 deltopectoral flap, 1 skin flap and 1 island pectoralis major musculocutaneous flap. An analysis of the procedures with emphasis on the oncological and functional results indicates that each techniques has advantages in specific circumstances. Guidelines for the application of the techniques are described.

[Deep neck infections in the antibiotic era]

The paper presents 43 patients treated between 1971 and 1995 in the Otolaryngology Clinic of the Pomeranian Medical Academy in Szczecin because of deep neck space infections. The authors analyse their own clinical material paying particular attention to the diagnosis, microbiology, patients prognosis and basic therapeutic procedures. Out of the 43 cases, deaths occurred in 3, which denotes 7% mortality rate. The reason for failure was discussed. It was revealed that needle aspiration and sonography were for valuable to identify early abscess formation. The analyses have confirmed that the prognosis of the deep neck space infections is influenced by early diagnosis and prompt, extensive surgical treatment.

[Treatment of bilateral vocal cord paralysis: surgical technique and functional results]

The authors present possibilities of the surgical treatment in bilateral vocal cord paralysis. We described the technique of the operation which is being used in our department in such a cases. 13 patients were analyzed after operations (11 women, 2 men). Bilateral vocal cord paralysis was caused by thyroidectomy (11 cases), virus infection (1 case) and in the course of multiple sclerosis (1 case). Functional results were evaluated by subjective examination, indirect laryngoscopy, spirometry and video-laryngoscopy. The effects of the treatment were satisfied.

[Extended fronto-lateral laryngectomy with epiglottoplasty]

The report presents our experience of 20 years in extended fronto-lateral laryngectomy with subsegment epiglottoplasty. Material comprised 35 patients aged 31-70. There were 3 female and 32 male patients. Clinical stage of the glottic cancer was: T1N0-in 22 cases and T2N0-in 13. Technique of the extended fronto-lateral laryngectomy and reconstruction of the larynx, using epilottis was presented. 3 and 5 years survival rate was achieved in 92% and 88% of cases respectively. Functional results were satisfactory.

[Reconstruction of the facial nerve in the parotid-masseter region]

The technique and results of surgical reconstruction of different extent of the extratemporal part of the facial nerve after oncological operations and after accidental injuries are reported. Return of facial nerve function was observed in 15 out of 17 cases (87%) with follow-up over 1 year. An own modification of nerve suture is described. Attention is called to the possibility of perineural and endoneural spread of parotid malignant neoplasms.

Arytenoid vocal shunt in laryngectomized patients

A method is presented for forming short, mucosa-lined vocal shunt in cases of supracricoid laryngectomy with preservation of one or two arytenoids, or the interarytenoid fold alone. On the basis of radiologic and particularly radiocinematographic examinationion of the anterior pharyngeal wall is of paramount importance. In cases of complete absence of leakage, said wall lies in the plane of the arytenoids or somewhat posteriorly. After simple supracricoid laryngectomy it is possible to prevent aspiration also by translocation of the anterior pharyngeal wall into the plane of the cricoid cartilage plate. The clinical experience with this supracricoid shunt is still scanty. Of 25 cases with the arytenoid vocal shunt, phonation was possible in 22 cases under the expiratory pressure of 20-45 cm H2O; in one under the more elevated pressure, and in the last two the result is still not known. Loudness of speech was 70-100 db and its comprehensibility 73-90 percent. Complete absence of leakage was observed in 17 cases, "practical" prevention of aspiration (some drops of thin fluids, no saliva) in seven cases, profuse leakage in one case (ceased after correction), In the last 10 consecutive cases the problem of aspiration was completely eliminated. Advantages and disadvantages of our own method in comparison with Asai's method have been presented.